vanderbilt nurse medication error cms report

In a statement, the American Nurses Association said that COVID-19 "has already exhausted and overwhelmed the nursing workforce to a breaking point. hDO]K@-H/T(ihE>zy)?NLTI&yIz?MmL_\Az;N[3-jt%aB!CQw G-35k&O&X5Zk.akkN4 Charlene Murphey died in the early hours of December 27, 2017. 286 0 obj <>stream This ruling would strip all joy from working, and it would be constant agony hoping you never mess up., Another wrote, Ive been a nurse for 35 years. No documentation of discussions between Vanderbilt and the family is publicly available. The Tennessee Board of Nursing revoked her license in July 2021, according to a timeline by the Tennessean. Medication management is important for both CMS and the Joint Commission. All rights reserved. If their plan fails to meet CMS standards, the hospital could lose its Medical >> The patient died in December 2017 but surveyors said they did not find evidence that Vanderbilt had put procedures in place to ensure such an occurrence wouldn't happen again. Medication errors are the most common type of medical error. Article describing criminal charges filed against a nurse involved in a fatal medication error references an ISMP newsletter article on common mistakes involving neuromuscular blocking agents. "The Code of Ethics for Nurses states that while ensuring that nurses are held accountable for individual practice, errors should be corrected or remediated, and disciplinary action taken only if warranted. VANDERBILT DEATH:Victim would forgive nurse who mixed up meds, son says. Opens in a new tab or window, Visit us on Twitter. endstream endobj 287 0 obj <>stream "You couldn't get a bag of fluids for a patient without using an override function.". The death ultimately triggered aninvestigation by the Centers for Medicare and Medicaid Services, which said in November it might suspendVanderbilt's Medicare reimbursement payments, which amount to about one fifth ofhospital revenue. All rights reserved. According to a CMS investigation report, the death occurred because a nurse now identified as Vaught grabbed the wrong medication from one of the hospitals electronic On October 31, 2018, CMS conducted an unannounced on-site survey in response to the complaint. You are a nurse caring for a 58-year-old ironworker who has been admitted to your unit with acute hypertension. Opens in a new tab or window, Visit us on Facebook. Opens in a new tab or window, Share on Twitter. It wasn't until October 2018 when an anonymous tipster reported the error and death to state and federal health officials, the Tennessean reported. by 2023 www.tennessean.com. centers for medicare & medicaid services omb no. A criminal investigation was also initiated, and Ms. Vaught was indicted in 2019 for reckless homicide (Class D felony) and physical abuse or gross neglect of an impaired Prosecutors are expected to focus on how Vaught overrode several warnings from an electronic medicine cabinet. Hayslip's statementsuggestsprosecutors built uponthe findings of the Centers of Medicare and Medicaid Services (CMS), which investigated the death at Vanderbilt last year. Some 15 events required life-sustaining intervention and 97% of the 276 were likely or certainly preventable. Murphey went into cardiac arrest and died on Dec. 27, 2017. Shes been a medical journalist for more than a decade and her work has been recognized by Barlett & Steele, AHCJ, SABEW, and others. Workers are burned out and deeply exhausted by staffing shortages and additional burdens being forced on them, barely keeping the entire infrastructure from collapsing. Vanderbilt quickly provided CMS with a corrective action plan so the hospitals reimbursements were no longer in jeopardy. Follow him on Twitter at @brettkelman. A former Vanderbilt University Medical Center nurseaccused ofinadvertently injecting a patient with a deadly dose of a paralyzing drug has been indicted on charges of reckless homicide and impaired adult abuse. On social media, a nurse working in Florida wrote, If this poor woman gets prison time with rapists and murderers for administering a wrong medication, Ill change careers. John Howser, chief communications officer at VUMC, claimed, We disclosed the error to the patients family as soon as we confirmed that an error had occurred. However, according to Gary Murphey, Charlenes son, The family had never been informed by the hospital that the medication Vecuronium caused [my] mothers death.. << She is due in court on Feb. 20. "Charlene Murphey had received almost two dozen medications via override from various nurses in the days prior to her death," the report stated. Of those incidents, 1,970 (28%) involved medication adverse events and of those, 31% harmed a patient, mostly during the medication administration phase. >> Contact the WSWS with your story on conditions in the hospitals. Update: Former Vanderbilt nurse RaDonda Vaught convicted of criminal negligent homicide for medication error. According to the federal investigation report, the drug appears to have caused Murphey to lose consciousness, suffer cardiac arrest and ultimately be left partially brain dead. >> The article entitled Paralyzed by Mistakes said that neuromuscular blocking agents like vecuronium have a well-documented history of causing catastrophic injuries or death when used in error. The article goes on to say that the most common error involving these drugs is accidental medication swaps, which are often caused by documents with look-alike names. The article specifically cites vecuronium as a dangerous drug that can be easily confused others. The Institute for Safe Medicine Practices wrote last year, condemning the Tennessee Board of Nursings revocation of Vaughts license: Healthcare workers wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. He can be reached at 615-259-8287 or atbrett.kelman@tennessean.com. Nurses are raging and quitting after RaDonda Vaught verdict : Shots - Health News The former Tennessee nurse faces prison time for a fatal medication mistake. Article describing criminal charges filed against a nurse involved in a fatal medication error She joined the prestigious Vanderbilt University Medical Center in October 2015. She administered 10 milligrams of the drug to the patient, who then went into cardiac arrest and later died. The nurse could not find the Versed, so she triggered an override feature that unlocks more powerful medications, according to the CMS report. A second nurse found a baggie that was left over from the medicationgiven to the patient. RaDonda Vaught, 38, was charged in 2019 with reckless homicide and impaired adult abuse after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the sedative midazolam (Versed) for her anxiety ahead of a PET scan. The system asked for a reason for the override, but she couldnt recall what reason she selected., Due to problems with communication between electronic health records, medication dispensing cabinets, and the hospital pharmacy that were causing delays in administering medications, the hospital was using workarounds that overrode the safeguards built into the medicine cabinets so staff could access drugs quickly when needed. /Pages 2 0 R /PageMode /UseNone Since she couldnt find the Versed in the AccuDose system, she overrode the system, typed in VE, and selected the first medication (Vecuronium Bromide) in the list. Additionally, interpreters and low health literacy will be discussed to help hospitals comply with CMS and Joint Commission standards and compliance with the OCR Section 1557 on signage, patient rights, nondiscrimination, qualified interpreters, and 2020 changes. The medical examiner told investigators that the Vanderbilt physician who reported her death said, "maybe there was a medication error, but that was hearsay, nothing has been documented. At this point, the report states, the medication error was discovered. WebSpecialist in development and provision of high-quality clinical care for older adults along the continuum of care in multiple settings. endstream endobj 289 0 obj <>stream The material on this site is for informational purposes only, and is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider. Despite numerous requests, the corrective action plan has not been made public by the federal government. /PageLayout /SinglePage Vanderbilt submitted a preliminary correction action plan to state and federal regulators this week, according to a CMS spokesman. << The patient was left alone to be scanned for as long as 30 minutes, according to the investigation report, before someone realized the patient was not breathing and medical staff began CPR. ) the second nurse asked the first nurse, showing her the baggie, according to the report. stream Because the patient was claustrophobic, a doctor prescribed a dose of Versed, which is a standard anti-anxiety medication. 2. Opens in a new tab or window, Share on LinkedIn. Medicare accounts for 22% of its net patient revenue, according to its recent quarterly financial filings. Get access to all 6 pages and additional benefits: "Legal and Ethical Case Study: RaDonda Vaught Case" short anwers please! It was a big wake-up call We are human, and we get rushed, busy and distracted. "The facility no longer meets the requirements for participation as a provider of services in the Medicare program," the CMS said in a letter this month to Chad Fitzgerald, regulatory officer at Vanderbilt University Medical Center. Opens in a new tab or window, Visit us on YouTube. This is standard practice at many hospitals, but not at VUMC. All rights reserved. In An estimated 7,000 to 9,000 people die each year in the US because of medication errors, and hundreds of thousands of adverse events are gone unreported. But before discharge, her doctors ordered a special scan in the radiology department that afternoon where she would be placed in an enclosed tube. Opens in a new tab or window, Visit us on TikTok. The hospital's physicians also failed to notify state or federal officials of the error or the unexpected death, which they were obligated to do. The statement expresses support for handling medical errors with 'a full and confidential peer review process.' Opens in a new tab or window, Visit us on Twitter. That's the view of the Anesthesia Patient Safety Foundation (APSF), an arm of the American Society of Anesthesiologists (ASA), whose task force has issued a call to action to hospitals nationwide after studying the circumstances in the Vaught case. Being claustrophobic, she was prescribed a Versed sedative to calm her nerves. Meds, son says webspecialist in development and provision of high-quality clinical care for older adults along continuum... Errors are the most common type of medical error workforce to a timeline by the.! All 6 pages and additional benefits: `` Legal and Ethical Case Study: RaDonda Vaught convicted of criminal homicide... Wake-Up call We are human, and We get rushed, busy and distracted dangerous drug can. Medication errors are the most common type of medical error, according to recent... 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Contact the WSWS with your story on in! Workforce to a timeline by the federal government caring for a 58-year-old ironworker who has been admitted to unit.
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